PERMIT TO WORK

1.0-Company _______________ Area _______________ Location __________________

PTW Valid from Date____________ Time_____________ PTW Valid Up to Date____________

Time: ___

2.0 Cold work Hot Work Confined Space Entry Excavation Permit Number:-
3-0 Description of the work- :

3.1 Fire watch / Confined space attendant required Yes No

If Yes Name of the Attendant Name of the fire watch

4.1. Atmosphere Monitoring Required Reading 4.4. Special Precautions/ Other Precautions Required Provided
1. Comb. Gas/Flamm. Vapor Test Yes No _____________________ 1. Ventilation __________________________________________ Yes No Yes No
2. Oxygen Concentration Yes No _____________________ 2. Lighting ____________________________________________ Yes No Yes No
3. Space Requires Purging Yes No __________ ( Min. Time) 3. Respirator __________________________________________ Yes No Yes No
4. Hazardous/Toxic Gas Test Yes No _____________________ 4. Other PPE __________________________________________ Yes No Yes No
5. Frequency of test Yes No Frequency: __________________________________________

4.2. Fire Prevention/Protection Required Provided 5. Access / Egress ______________________________________ Yes No Yes No
1. Fire Exiting/Equip. Yes No Yes No 6. Other ______________________________________________ Yes No Yes No
2. Comb/Flamm Mat’l Insulated Yes No Yes No 4.5. Additional Training Required Provided
3. Fire Watch Yes No Yes No ____________________________________________________ Yes No Yes No
4. Yes No Yes No
4.3. Electrical Safety Check Required Provided ____________________________________________________ __________________________
1. Switchgear locked out? Yes No Yes No 4.6. Rescue Plan / equipment Yes No Yes No
2. Fuse blocks pulled? Yes No Yes No
3. Power source shut down/discon? Yes No Yes No
4.7. Additional Comments:

5.0 Receiver –Supervisor/Char hands Issuer - ABE Project Engineer Approved By EHS -: Closed Out (Signed by Issuer & Receiver)
Name Name Name Name
Function Function Function Function
Signature Signature Signature Signature
Note: This permit is valid only for the activity, date and time specified. This permit shall be posted at the work site during the work activity. If the terms noted change, work must stop and the permit will be re-issued. Fire and
Emergency Alarms automatically invalidates the permit. Permit shall be invalidates if subsequent gas tests do not meet the established limits or if any unsafe condition arises When the work is complete or the permit expires,
return the permit to the HSE office marked complete.
6.0 Date: From-Hrs To Hrs Permit Receiver Permit Issuer Approved By Extended Hrs Issuer Approved By

Permit Renewal

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 ABE-HSE-F-035,Rev

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 CONFINED SPACE PERSONNEL ENTRY LOG

Permit Number -__________________________________

Description of the Confined Space: __________________________________________

Entry Supervisor: ____________________________ Date: _____/_____/_____

Attendant(s):_____________________________________________________________

ENTRANT'S NAME ID NUMBER TIME TIME TIME TIME TIME TIME

IN OUT IN OUT IN OUT

NOTE: RETAIN WITH THE CONFINED SPACE ENTRY PERMIT

ABE-HSE-F-035,Rev.00

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 SUBSEQUENT TEST RESULT

Permit Number -__________________________________

Area: _______________________ Location: _____________________________

O2 LEL CO H2 S Date Time Sign Remarks

NOTE: RETAIN WITH THE RELEVANT PTW -

ABE-HSE-F-035,Rev.00

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